Primary Select Platinum Plan: Health Republic Insurance of New York Coverage Period: 01/01/ /31/2015

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This is only a summary.

If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702.

Important Questions Answers Why this Matters:

What is the overall deductible?

$0/person $0/family

Benefits not subject to deductible include: preventive care, PCP, Specialist & other practitioner visits, generic prescription drugs, diagnostic tests, and imaging.

You must pay all the costs up to the deductible amount before thisplan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other

deductibles for specific

services? No.

You don’t have to meet deductibles for specific services, but see chart starting on page 2 for other costs for services this plan covers.

Is there an out–of– pocket limit on my expenses?

Yes. $1,400 /person $2,800 /family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out–of–pocket limit?

Premiums and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a

Yes. See http://healthrepublicny.org/for-members/find-a-provider/ or call

1-888-If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the

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Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

•

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

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The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

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This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common

Medical Event Services You May Need

Your Cost If You Use a Participating

Provider

Your Cost If You Use a

Non-Participating

Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness $0 copay/visit Not covered –––––––––––none––––––––––– Specialist visit $75 copay/visit Not covered –––––––––––none––––––––––– Other practitioner office visit $75 copay/visit Not covered –––––––––––none––––––––––– Preventive care/screening/immunization No charge Not covered

If you have a test Diagnostic test (x-ray, blood work) $75 copay/visit Not covered –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) $75 copay/visit Not covered –––––––––––none–––––––––––

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Common

Provider

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at

http://healthrepublicn y.org

Selected generic drugs

Retail: $0

copay/prescription Mail order: $0 copay/prescription

Not covered Covers up to a 30-day supply (retail prescription); 90 day supply (mail order prescription)

Preferred brand drugs

Retail: $35

Non-preferred brand drugs

Retail: $70

Not covered

Covers up to a 30-day supply (retail prescription); 90 day supply (mail order prescription)

Specialty drugs

Retail: $70

If you have

outpatient surgery Facility fee (e.g., ambulatory surgery center) _{Physician/surgeon fees} 20% coinsurance _{20% coinsurance} Not covered _{Not covered} –––––––––––none––––––––––– _{–––––––––––none–––––––––––}

If you need

Emergency room services $250 copay/visit $250 copay/visit after deductible is met

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Common

Provider

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services $0 copay/visit Not covered –––––––––––none––––––––––– Mental/Behavioral health inpatient services 20% coinsurance Not covered –––––––––––none––––––––––– Substance use disorder outpatient services $0 copay/visit Not covered –––––––––––none––––––––––– Substance use disorder inpatient services 20% coinsurance Not covered –––––––––––none––––––––––– If you are pregnant Prenatal and postnatal care No charge Not covered –––––––––––none––––––––––– Delivery and all inpatient services 20% coinsurance Not covered –––––––––––none–––––––––––

If you need help recovering or have other special health needs

Home health care $15 copay/visit Not covered 40 visits per year

Rehabilitation services $30 copay/visit Not covered 60 visits per condition per lifetime Habilitation services $30 copay/visit Not covered 60 visits per condition per lifetime Skilled nursing care 20% coinsurance Not covered 200 days per year

Durable medical equipment 20% coinsurance Not covered $1,500 per year Hospice service

Inpatient: 20% coinsurance Outpatient: $15 copay/visit

Not covered 210 days per year

If your child needs dental or eye care

Eye exam $15 copay/visit Not covered Limited to one exam per 12-month _period Glasses 20% coinsurance Not covered Limited to one pair of glasses per year Dental check-up Not covered Not covered –––––––––––none–––––––––––

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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) • Cosmetic surgery

• Dental care (Adult)

• Long-term care

• Non-emergency care when traveling outside the U.S.

• Private-duty nursing • Routine eye care (Adult) • Routine foot care

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• Acupuncture • Bariatric surgery • Chiropractic care

• Hearing aids

• Infertility treatments

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Your Rights to Continue Coverage:

Group health coverage

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-888-990-5702. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or

www.cciio.cms.gov.

Language Services:

SPANISH (Español): Para obtener asistencia en Español, llame al 1-888-990-5702.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: 1-800-342-3736.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

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Having a baby

(normal delivery)

Managing type 2 diabetes

(routine maintenance of a well-controlled condition)

About these Coverage

Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

n Amount owed to providers: $7,540 n Plan pays $5,990

n Patient pays $1,550

Sample care costs:

Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $0

Copays $620

Coinsurance $780

Limits or exclusions $150

Total $1,550

n Amount owed to providers: $5,400 n Plan pays $4,210

n Patient pays $1,190

Sample care costs:

Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700

Education $300

Laboratory tests $100 Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $0

Copays $860

Coinsurance $250

Limits or exclusions $80

Total $1,190

This is

not a cost

estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for

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Questions and answers about the Coverage:

What are some of the

assumptions behind the

Coverage Examples?

• Costs don’t include premiums.

• Sample care costs are based on national averages supplied by the U.S.

Department of Health and Human Services, and aren’t specific to a

particular geographic area or health plan. • The patient’s condition was not an

excluded or preexisting condition. • All services and treatments started and

ended in the same coverage period. • There are no other medical expenses for

any member covered under this plan. • Out-of-pocket expenses are based only

on treating the condition in the example. • The patient received all care from

in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example

show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or

treatment isn’t covered or payment is limited.

Does the Coverage Example

predict my own care needs?

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No. Treatments shown are just examples. The care you would receive for this

condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example

predict my future expenses?

û

No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples

to compare plans?

ü

Yes.

When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should

consider when comparing

plans?

ü

Yes.

An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.